HomeMy WebLinkAbout7-Eleven, Inc. - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Retail Establishment
In accordance with Regulations promulgated under authority of Chapter 94, Section
305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
7-ELEVEN, INC.
Whose place of business is: SUNOCO 40082H
70 COPELAND DRIVE
Permit Expires December 31, 2019
License Number: RF-12
Food Fee: $100.00 Milk & Cream
BOARD OF HEALTH
Michae[HeaCey, Chairman
Permit or the Sale of Tobacco Products
Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION
OF TOBACCO may result in fines, suspension or revocation of this permit.
Whose place of business is: SUNOCO 40082H
70 COPELAND DRIVE
License Number RF-12
Permit Expires December 31, 2019
BOARD OF HEALTH
NichaeCHeaCey, Chairman
JC
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W11_7 ' 'i' R BOARD OF HEALTH USE ONLY
.
ABLISHMENT PERMIT APP
(Applicati ttmust be submitted at least 30 days before the
I C 2018
date)
Establishment Name: S�_VVNp C () .`
Establishment Address: -10 c'opa,�'c14 br., �,p�,S�ye,) MA o?,48
Establishment Mailing Address(if different): q 7-
Establishment Telephone No.: 9)� -* 33 T -- Ll Q
Applicant Name &Title: -C-Ir2ne411,-) bA/C 0
Applicant Address: ZCn® t GaLV`6err'j
Applicant Telephone No.: [,t-f "7 Q �' 24 Hour Emergency No.:
Applicant E-mail: 0 V►\(_j p Q,_O�z_ Q., -]- I r'C owl
Owner Name & Title (If different from applicant):
Owner Address:
Owner Telephone No.:
Owner E-mail:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
0 An Association
1?1�"Corporation
partner.
Name a Title Address
O An Individual—
O A Partnership
�r
O Other legal Entity
/
Person Directly Responsible For Daily Operations (owner, personin charge, supervisor, manager etc.)
,r
Name & Title: O pe `p� aS Nkr Y' 01�D1� �� tiYtR9 P Y
Address: `1
Z 310
Telephone No: SQ �p� R — ®I 24 Hour Emergency No: "1
FAX:
E-mail:
Alt E-Mail: L-° b ` S , Cs
District Or Regional Supervisor (if applicable) I �f
"C*-r C-y4vVGA "`-0-W Coh ' ' " 1
Name & Title: r cAvie 4-
Address: „ [�r�S'� OI ��Q �,fo o�vi-i (,�A`A-
yryO'23t0�L
Telephone No: 2�p7 - �� i �\� 0' 24 Hour Emergency
FAX:
�y1� `l n
E-mail: ® /a.Q1QGJi%�' ���1• C Owl
Food Establishment Information
SEWAGE DISPOSAL:
WATER SOURCE: �� V �
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
2- --^
Name of Person In Charge Ce ified in Food Protection Management
If more than 3 individuals are certified, complete
list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more): E3
Location: ermanent Location
Establishment Type
Q Caterer $35.00
Mobile Mobile Start Date:
(Retail (S� Sq. Ft) [-Mil
c Cream $10.00
Mobile End Date:
- ;d Service up to 100 INCLUDING
Mobile Food Consesslon
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
Mobile Comments:
—
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Length of Permit:
Food Service up to 101 -200 $250.00
nual
I Food Service up to 201 + $300.00
I Pushcart $50.00 # of Pushcarts:
E] Residential Kitchen $100.00
I] Seasonal
Ej Supermarkets $400
n- etail Food $125.00
Seasonal Dales:
Retail Snack Food $50.00
n Temporary
Temporary Start Date:
a obacco Products $150.00
Temporary End Date:
Temporary Time:
Rain Date:
Operations
Foodt
Definitions:PHF - Potentially hazardous food(fimeRemperature controls required)
Non-PHFs - non -potentially hazardous food(no limertemperatme controls required)
muffins which need no further processing)
(Check:
RTE-
ready -to -eat to (Ex. sandwiches, salads,
_
alially Pre -Packaged Non-PHFs -
0 PHFCooked To Order
EJ Hot PHF Cooked and Cooled of Hot Held
for More Than a Single Meal Service
alially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
0 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
EJ Deaged PHFs
EJ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
acuum Packaging I Cook Chill
Reheating of Commercially
Q Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
contact alternative, time as a public health
Processed Foods for Service Within 4 Hours
El Customer Self -Service of Non PHF and Non-
i7777 Customer Self -Service
ce Manufactured and Packaged for
Retail Sale
Ih� , Manufactured and Packaged for
Perishable Foods Only
control)
reparation of Non-PHFs
[3 Offers Raw Or Undercooked Food Of
Other Food Operations
Retail Sale
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
E] Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee:
Payment is due with application Q waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply with 105 C 5 . 00 and all other ap licable w. I have been instructed by the
board of health on how to t \n copies of 105 M 590. 00 and the feder ood C e.
i
Signature of Applicant
Pursuant to MGL Ch.62C, sec. 49A, I certify and I penalties of perjury that my best knowledge and belief, have filed all slate lax returns
and paid state taxes required under law. — I— I '
Signature of Individual or Corporate Name: I — k%—lV'C7rr�r
Social Security Number or Federal ID: ' I S" 4 0 2 .S `
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
f 1
Signature of Individual or Corporate Name By: Corporate cer (Mandatory, if placable)
-is,4(4 S r�> I
*"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Seelrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wow. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Lel=ibly
Business/Organization
Address:
City/State/Zip:
Are
�tyou an employer? Checic th appropriate box:
1.19- r am a employer with _ _v employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #:� �®
Business Type (required):
5. etail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
1o.❑ Manufacturing
I1.❑ Health Care
12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy intormanon.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing 1Korkers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address:
/Z'
eL-L
Crty/State ]p. —ttt, p �( ^
Policy # or Self -ins. Lie. # ay L �' �S tr Expiration Date:_�!V=�_`.�_..--
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct.
n_ _ n � i' l , jV ----I R'
_A2
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone #:
A oho® CERTIFICATE OF 'LIABILITY INSURANCE
DATE (10/01/18)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSITUTE A CONTACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policies may require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:
AON Risk Services Southwest, Inc.
Dallas Location
2711 North Haskell Ave, Suite 800
PHONE
(AID, No. Exn:
866) 283-7122
FAX
(AIC, No):
(847) 953-5390
E-MAIL
ADDRESS
INSURERS AFFORDING COVERAGE NAIC#
Dallas, TX 75204
INSURER A: ''�. Mitsui Sumitomo Insurance Co of America 20362
(214) 989-0000
INSURED
INSURER B: ACE American Insurance Company', 22667
INSURER C: Indemnity Insurance Co of North America '''�. 43575
7-Eleven, Inc.
One Arts Plaza
1722 Routh Street, Suite 1000
INSURER D:
INSURER E:
Dallas, TX 75201
rnVFRAr.FS CERTIFICATE NUMBER REVISION NUMBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUER
WVD
POLICY NUMBER
POLICY EFF
DATE (MMIDD/YY)
POLICY EXP
DATE (MM/DD/YY)
LIMITS
B
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADEFX OCCUR.
OWNERS' & CONTRACTOR'S PROT.
LIQUOR LIABILITY
$500,000 SELF INSURED RETENTION
EACH OCCURRENCE
$
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any One Person)
$
PERSONAL&ADV. INJURY
$
GENERAL AGGREGATE
$
PRODUCTS-COMP/OP AEG
$
B
AUTOMOBILE
LIABILITY
ANY AUTO
ALLOWNEDAUTOS
SCHEDULED AUTOS
HIREDAUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per Person)
$
BODILY INJUR
(Per Accident)
$
PROPERTY DAMAGE
(Per Accident)
$
A
EXCESS
X
LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
$
AGGREGATE
$
C
B
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETOR/ Yes
PARTNERS/EXECUTIVE X No
OFFICER EXCLUDED
LR C65435706
ADS
SCF C65435780
I
LR C65435743
Z/CA/MA
10/1/2018 -
'10/1/?019 :.
x WC STATU-TORYLIMITS
other
EL EACH ACCIDENT
1 $1
1,600,000
EL DISEASE -POLICY LIMIT
EL DISEASE - EA EMPLOYEE
$
$
1,000,000
1,000,00o
B
OTHER
Ea. Common Cause
Aggre ate
ADS
DESCRIPTION OF OPERATIONSILOCATIONSA/EHICLES/SPECIAL ITEMS
Evidence of Workers Compensation Coverage for all 7-Eleven Corporate Stores
Whom It May Concern
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
SERVICES
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: Joseph T Burroughs
Date of Completion: November 16, 2016
Date of Expiration: November 16, 2021
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Town of Mansfield - Board of Health
PERMIT NUMBER:
Application for the Sale of Tobacco
i
5oW
Town of Mansfield
6 Park Row
Mansfield, MA 02048
EM
I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation
Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on December 31st of
each year. Violation of this Regulation may result in fines, suspension or revocation of this permit.
NAME OF BUSINESS: S \'k WA Q C+-
LOCATION OF SALE OF TOBACCO PRODUCTS:
TELEPHONE AT LOCATION
OWNER OF BUSINESS:
LI-0 Q 9 E4
E
�c -1 1 f %C-- I
ADDRESS OF OWNER:.72-H 1 ( (AG l� Jey � -KA\ Y v' �� , S'
TELEPHONE OF OWNER: q�, - --%
FAX NUMBER:�2
If a corporation or partnership, give name, title, and home address of officers or partner.
* Provide a copy of current Department of Revenue CT-3T Retail Excise Unit License.
FEE: $150.00
CT3TNUMBER:
FEDERAL ID/SS NUMBER:
SIGNATURE:
DATE:
STATE OF MA
LIST OF OFFICERS
Joseph M DePinto
Pres/CEO
Rankin Gasaway
SVP/GC/SEC
David Seltzer
VP/TR
POWER OF ATTORNEY
Know all persons by these presents that 7-Eleven, Inc. ('7-Eleven" or the "Company"), has
made, constituted, and appointed, and by these presents does hereby make, constitute, and
appoint Cheryl Swinford;
Its true and lawful attorney -In -fact, for It, and in Its name, place, and stead, to take all actions
necessary and appropriate to renew, apply for and obtain any licenses, permits or similar
services Incidental to the business of the Company including, but not limited to, the following
categories:
• alcoholic beverages;
• lottery;
• tobacco;
• food processing;
• food service;
• food products/retailing;
• volatile chemical; and
• utilities.
Also included are any and all other documents relating to or necessary for the issuance or
transfer of such licenses, including but not limited to guarantees to the licensing agency, and to
assign and reassign any and all necessary papers in connection therewith, giving and granting
unto its said attorney -in -fact full power and authority to do and perform all and every act, as to
all intents and purposes as it might or could do, with full power of revocation, hereby ratifying
and confirming all that its said attorney -in -fact shall lawfully do or cause to be done by virtue
hereof:
The individual appointed as an attorney -in -fact herein shall remain an attorney -in -fact with the
authority granted herein for until such appointment is otherwise revoked by 7-Eleven.
In witness whereof, said 7-Eleven has caused these presents to be signed by its proper
corporate officer as of May 1� 2016.
7-ELEVEN, INC.
Attest:
rrv,114-1�
�
B:?!�-- 44-��
Rubinett Rankin L. Gas v ay
Secretary Senior Vice President
17765SY13
State of Texas
County of Dallas
On this I_ day of , 2016, before me, the undersigned notary
public, personally appeared Rankin L. G saway and Arthur E. Rubinett a Senior Vice President
and an Assistant Secretary, respectively, of 7-ELEVEN, INC., a Texas corporation, known to me
to be the persons whose names are subscribed to the foregoing instrument, and acknowledged
to me that the same was the act of the said corporation and that they each executed the same
as the act of such corporation for the purposes therein expressed and in the capacities therein
stated.
In witness whereof, I hereunto set my hand and official seal.
C1
(Notary ubiic signature)
5Lakrt I/te._ Lb tr-trts wU
(typed or printed name)
(S
SUZANNE HARRISON
�#) Notary Public, Spur of Tani
r My Comm. Explres09-23-2017
+� L.' Notary 10252632.3
177658vl3
Commonwealth of Massachusetts Letter to: 1,1667420800
i' Department of Revenue Notice Date: September 14. 2018
Christopher C. Harding, Commissioner Account ID: CGL-101963345-110
"@rvrurr mass.govtdor
RETAILER LICENSE FOR SALE OF CIGARETTES
llhgtrllllprgr111irlhtlllllrvrrPllh61hlq1dPlulhll
7 ELEVEN INC
7-ELEVEN 31445H
PO BOX 711
DALLAS TX 75221-0711
Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line
and display at your business location. At any time, you can log into your MassTaxConnect account at
mass.gov/masstaxconnect to view and re -print a copy of this license.
If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at
(800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
oeNod
6 _Sync"uss MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
o Retailer License for Sale of Cigarettes
'�'eivr oF"' This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
"7ELEVEN INC - AccountID: COL-10196336-110
SUNOCO #40082H Location ID: 10196336-0704
70 COPELAND DR License Number: 222687232
MANSFIELD MA 02048-1221
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: October 1, 2018 Expiration Date: September 30, 2020
q
CammonwealtN of Massachusetts Leticr ID: L2011093680 o
p Department of Revenue Notice Date: September 20, 2018
Christopher C. Harding, Commissioner Account to: CRL•10196336-1 13
aid mass.govldor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
Irdulbt4ltPthdihldlr4ttIIII111itI11111ht4tPntllr�il
7 ELEVEN 1NC
7-ELEVEN 0444WH
PO BOX 711
DALLAS TX 75221-0711
Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut
along the dotted line and display at your business location. At any time, you can log into your
MassTaxConnect account at mass.govlmasstaxconnect to view and re -print a copy of this license.
If you have any questions about your license, call us at (617) 887-6367 or toll -free in Massachusetts at
(800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
sr:HUSF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
m Retailer License for Sale of Cigars and Smoking Tobacco
This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
7 ELEVEN INC Account ID: CRL-10196336-113
SUNOCO #40082H Location ID: 10196336-0705
70 COPELAND DR License Number: 730755072
MANSFIELD MA 02048-1221
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non -transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date. October 1, 2018 1 Expiration Date: September 30, 2020